Metformin: decreases hepatic glucose production and peripheral glucose utilization, decreases intestinal glucose absorption (these are reasons it leads to weight loss), can cause lactic acidosis and needs to be discontinued 24 hours before contrast and resumed 48 hours after with monitoring for creatinine, stop if creatine is > 1.5

Pioglitazone (Actos) is a thiazolidinedione (TZD) and decreases insulin resistance and increases glucose utilization by sensitizing peripheral tissues to insulin.

Question 2

A 66-year-old male was found wandering in the streets by the police. There are no signs of trauma. BP is 90/54 mm Hg, pulse rate is 115 bpm, and respiratory rate is 12 breaths/min. Physical exam reveals mild dehydration as well as decreased mental state without focal neurological findings. Initial laboratory findings include glucose of 750 mg/dL, Na of 124 mEq/L, K of 3.0 mEq/L, Cl of 102 mEq/dL, CO2 of 37 mEq/L, BUN of 101 mg/dL, creatinine of 1.0 mg/dL, blood pH of 7.3. Which of the following is the most appropriate first step in managing this patient?

A

glucagon

Hint:

Glucagon would further increase the blood glucose

B

insulin

Hint:

Insulin is typically not needed unless the glucose is resistant to fluids

C

bicarbonate

Hint:

Bicarbonate should not be administered because the blood pH is above 7.0

D

saline

Question 2 Explanation:

Hyperglycemia in the absence of ketosis is common in elderly type 2 diabetics. With mild dehydration, sodium is low but rises as the dehydration worsens. Elevated BUN is key to diagnosis. This patient is presenting with hyperglycemic hyperosmolar state and is dehydrated. Correction of the hypovolemia will reduce the hyperglycemia and thereby allow the kidneys to excrete the glucose

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